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Home My WebLink AboutApp-Permit-ComplianceF THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................................... OF ............ /.X ............................................... Appliration for Disposal Works Tonstrudion Prrmit Application is hereby made for a Permit to Construct (� or Repair an Individual Sewage Disposal System at: .7 .4eq .. ....... ...... ......................... ..... ....... ffij5-.-----.------.a..................... Ep Loc ...... ; ti n Address or Lot 1�9, r ... Ik & I . .... . ......................... ..................................... ....... �> --------- -------------------- ss . ......... ... Owner Installer Address Type of Building Size Lot ............................ Sq. feet Dwelling —No. of Bedrooms ............ 3 ............................Expansion Attic Garbage Grinder P4 Other —Type of Building ............................ No. of persons...................._....... Showers Cafeteria 134 Other fixtures ...................................................................................................................................................... Design Flow ............................................gallons per person per day. Total daily flow ............................................ gallons., Septic Tank — Liquid' capacity............ gallons Length ................ Width ................ Diameter ................ Depth ................... Disposal Trench — No. -------------------- Width.................... Total Length......._........_... Total leaching area .................... sq. ft. Seepage Pit No ..................... Diameter .................... Depth below inlet.--................. Total leaching area .................. sq. fu. Z 'P; er Distribution box ( ) Dosing tank( ) Percolation Test Results Performed by ........................................ -----------•-------••-------...... ----- * ............. Date--------------------------------........ ."-Test Pit No. I ................minutes per inch Depth of Test Pit.............._..... Depth to ground water ........................ Test Pit No. 2 ................minutes per inch Depth of Test Pit..._................ Depth to ground water........................ ...................... ............................................................................. ......................................................... 0 Description of Soil ........................................................................................................................................................................ ----------------------------------- " --------------------- * ---------------------------------------- * ----------------------------------------------------------------------------------------------- ............................................................................................................................. ------------ ------------------------- - .... ..................... U Nature of Repairs or Alterations —Answer when applicable ........... ........ ................... ........... ....... .......................................................................................................... ............................ ..................... ................................ Agreement: _T �w The undersigned agrees to install the aforedescribed Individual Sewage Dispogal System in accordance with the provisions of T I T 1Z- 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beensisued Vbyv oard of heal e!P .................... Application Approved By.� ------------ S .. --...................................... .......... Date Application Disapproved for the following reasons: ........................................................................................................ ....... . Date Permit No ......... ................ Issued_. o_ -A— ............. ..... .... ....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE,#,LTH ...................... OF ................ d.f.) ....... .......................................... .. ... ... .... ... Trrtifiratr of ToutpHaurr THIS,V TO CERTIFY, That the Individual Sewage Disposo.System constructed (-,�) or Repaired yb ............. el-lon,35-f nuc.:±1104 ...... ................................................. Installer ... a ................................................................................................... at ......... has been installed in accordance with the provisions of TITLBF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit dated_.be.#...2 THE ISSUANCE OF THIS CERTIFICATE SHAUNNOT BE CONSTRUED AS A GUARANTEE IAT THE SYSTEM 1N LL FUN TON SATISFACTORY. � DATE .. ................. Inspeq......................................... .... um . (9r 1� .... No...6 .... . ..... . FZz ........ . . ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. a ....... OF ............... Y _. I Appliration for Dispvaal Works Tonstrudion jitrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: r..... L ........................... Location - Address .................................. Owner I Installer Type of Building Dwelling —No. of Bedrooms ............. ------- Other —Type of Building ................. ...... Other fix ures ................... -- --------- -_ \ ;I Design Flow, g2 ons �rr --- -------- Is Septic Tank — Liquid' capaci'*'"14 ---------- s� L =.gallon Le Disposal Trench — No . .................... Width_..........__..... \\ Seepage Pit No ....... ............ Diameter......,. -j,,,,_.- e: Other Distribution box �4) Dosing tank Percolation Test Results Perfo e i -Test Pit No. L-- ...minute _'11nc ' Dept p Test Pit No. 2 ................minutes ,, e .inch Depth ...................... Expansion --- No. of Dersons ......... Description of .............................................................. Nature of Repairs or Alterations — ..................................................................... Agreement: The undersigned agre to install L o T f S the provisions of T I T LZ 5 of State operation until a Certificate of Com 'an Application Approved By_'.-�� Application Disapproved for the following or Lot No. Address Address Z49 -e� -Z_ Size Lot ............................. Sa. feet A is ( ) Garbage Grinder ...... ............ Showers ( ) — Cafeteria ............................................................................................. #y.Total ilr fl9w ............ .................. ons. otal_____ 7...Width:._.q,.J0. Diameter ................ Depth.V 4! ,ength ------ ------------ Total leaching area .................... sq. ft. inlet..._ .... Total leaching are,�_ZAE4 ----sq. ft. 4 . ......... Date ... Z�.fi ..... 4� It— --- ------ t E, ../4aD ......... Depth to ground water../.A(dAYE... t`pit .................... Depth to ground water.............__......... ............................................ 4-f .............. ........................................................................................... ........................................................................................... aforedescribed Individual Sewage Disposal System in accordance with ary C9deue The undersigned further agrees not to place the system in een issued by the board of health. .............pate .. Date .................................................................................................................................................... ... Date Permit No.. ...................... ......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ..................................................................................... (9rdifirab of Tout pliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by-------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Installer at...................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ......................................... dated--............._--.....--....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.--•..............................•-•-•----.........------------------.......... Inspector .................................................................................... A P*